- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.67 / $190.67 / $190.67
| Facility | | $190.67 | $190.67 | $190.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.67 / $383.69 / $589.91
| Professional | | $190.67 | $383.69 | $589.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.57 / $40.57 / $40.57
| Professional | | $40.57 | $40.57 | $40.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.40 / $262.24 / $589.91
| Facility | | $51.40 | $262.24 | $589.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.87 / $51.40 / $416.82
| Professional | | $30.87 | $51.40 | $416.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.53 / $27.73 / $276.36
| Professional | | $23.53 | $27.73 | $276.36 |